The implication of crew’s decision making

to flight safety

Presented by

Danny Ho

EVA Airways Corporation

April 23-24, 2015

Contents

• Introduction

• Lesson Learned

• Decision Making Theory

• Best Practices

• Conclusion

您的夢想－卓越飛行員一位卓越的飛行員，乃在於能運用其卓越的決斷能力

來避免須運用其卓越操作能力狀況的發生。

To achieve a safe operation, crew’s

‒ burden is heavy

− pressure is high

4

Contents

• Introduction

• Lesson Learned

• Decision Making Theory

• Best Practices

• Conclusion

Human deficiency

is the primary risk to aviation safety.

6

Lesson Learned

To forget is to invite the repetition of tragedy !

Broken Window – Unstable Approach

A A320 enroute to JFK, during descent, flight deck received a call from cabin that “one passenger had his hand cut and bleeding”. Captain declared medical emergency and took over the control from F/O. A/C being cleared for visual approach RWY 31R. After landing paxwas treated by airport medical personnel.

The Captain of this flight write a ASAP report and mentioned “the approach was kind of fast and kind of unstable”.

What kind of fast and what kind of unstable

Alt SPD

(kts)

IVV SPD

Brake

Flap Gear

1000’

500’

100’

3’

221

208

181

156

2500’ Deployed

“

“

“

0

0

3

Full

Extended

Spoiler being armed 2 seconds prior to touch down.

A/C fly low 2 dot below the G/S.

A/C landed 5000’ down the runway when abeam terminal building.

EGPWS Warning : Capt. Said he didn’t hear –they turn off.

No landing check.

During interview F/O said “I can’t believe, I let him do it” after saw the FOQA animation.

Put 161 people in danger because you want to save one pax.

International Air Safety SummitInternational Air Safety Summit

Accident approach versus criteria

• The agency also said the pilots for the Seoul-

based airline committed at least 20 errors in

the final 14 miles of approach to the airport.

It cited "mismanagement" by pilots as the

probable cause of the crash.

Why PIC of this B737-400 landed with 221kts which exceeded

87kts of its Vref ?

15 EGPWS Warning + G/A call out by F/O

—Why no G/A ?

International Air Safety Summit

Why a well trained & licensed crew made such

flowed decision that not only endanger his/her

life but also hundreds onboard ? Why?

The vital elements to

eliminate human

deficiency are:

Safety Oriented Mindset

&

Professionalism

How important of mindset

Mindset dominate our behaviors

Behaviors form our habits

Habits create our attitude

Attitude cultivate our characters

Characters decide our destiny

is not the job you do,

but how you do your job!

Professionalism

Professionalism

“Professionalism is a state of mind.

It’s not something I do, it’s something I am.”

－Capt. Dave Ryter

Chairman, National Education Committee,

Professional Development Group,

Air line Pilots Association, International

Professionalism

“In aviation,

one mistake is one too many!

Either fly right or don’t fly!”

－Capt. Randy Babbitt

former FAA Administrator

20

Contents

• Introduction

• Lesson Learned

• Decision Making Theory

• Best Practices

• Conclusion

Safety Oriented Mindset

Decision Making

Actions

Safe Operation

How to make a sound judgment & decision ?

Decision Making Theory

Understanding : Understand what is problem.

Comprehension : Comprehend the problem.

Strategic Planning : Thorough & Comprehensive

Decision Making : Precise

Execution : Accuracy & Decisive

SKILL-based Behaviors (“I Know/I am Able”)

WISDOM-based Behaviors (“I Lead/I Choose wisely）

RULE-based Behaviors (“I Understand/I will Comply”)

Safe Operation

Contents

• Introduction

• Lesson Learned

• Decision Making Theory

• Best Practices

• Conclusion

How you are going to handle it ?

If your A/C is entering a pitch down acceleration,

no response from your full back stick input, no

ECAM Warning, how you are going to handle

this ?

A/C was out of control for 20 seconds with

Pitch attitude : -10o

V/S : 9300 ft/min

Mach : 0.87

SPD : 347kts

FSF Safe Landing Guideline

1. Fly a stabilized approach

2. Height at threshold crossing is 50 feet

3. Speed at threshold crossing is not more than Vref + 10

knots indicated airspeed and not less than Vref

4. Tailwind is no more than 10 knots for a non-

contaminated runway, no more than 0 knots for a

contaminated runway

5. Touchdown on runway centerline at the touchdown

aim point

Safe Landing Guideline

6. After touchdown, promptly transition to desired

deceleration configuration:

– Brakes

– Spoilers/speed brakes

– Thrust reversers

Note: Once thrust reversers have been

activated, a go-around is no longer an option

7. Speed is less than 80 knots with 2,000 feet of runway

remaining

+ Once loss visual cue, G/A !

“Go around due to unstable below 1000 feet.”

“Due to bad weather & cross wind over limit, forecast weather also no good, after go around we decided to divert to alternate.”

“Flare at 30ft suddenly gust tailwind come on and keep aircraft to float. Execute go around, and vector for second approach.”

DECISIONS :Safe

Timely

Decisive

Informed

Contents

• Introduction

• Lesson Learned

• Decision Making Theory

• Best Practices

• Conclusion

How can you make a safe decision ?

Always put safety oriented mindset on your decision

making process and execute it via your professionalism !

• We are human, we all make mistake !

• Learn from past, do our best at present and aim for

better in the future !

Safety is a shared responsibility!

Safety

No one is perfect, but a team can be!

Change your mindset,

you can change your world!

Want me safe I want safe!

Thank you.